Bullying Report Form

Pinellas County Schools Logo

Pinellas County Schools Bullying/Harassment or
Teen Dating Violence and Abuse Report Form
 
Complete this form to report a possible incident of bullying/harassment or Teen Dating Violence and Abuse as defined in the Pinellas County Schools' Policy against Bullying and Harassment or the Pinellas County Schools’ Teen Dating Violence and Abuse Policy for secondary students.

Bullying is systematically and chronically inflicting physical hurt or psychological distress on one or more students or employees and may involve but is not limited to teasing; social exclusion; threat; intimidation; stalking; including cyber stalking; physical violence; theft; sexual, religious, or racial harassment; public humiliation; and destruction of property.

Teen Dating Violence and Abuse is a pattern of emotional, verbal, sexual, or physical violence and/or abuse by one person in a current or past relationship of a romantic nature to exert power and control over another when one or both of the partners is a teenager.

* Fields with this red star are required, everything else is optional. Bullying or Teen Dating Violence and Abuse can be reported anonymously.
 

About the Victim
 About the Accused
 About Yourself (Optional)
  Victim First Name: * Accused First Name: * Your First Name:
  Victim Middle Initial: Accused Middle Initial: Your Middle Initial:
  Victim Last Name: * Accused Last Name: * Your Last Name:
  Victim Grade/Position: * Accused Grade/Position: Your Grade Position:
  Victim Gender: * Male
Female
 Accused Gender: Male
Female		 Your Gender: Male
Female
  Victim Disabled: * Accused Disabled:    


About the Incident



  School/site where the incident occured: *     
  Incident Date: * Enter Date      
   
       

Describe the location where the incident took place: *

  

Describe the incident and list all witness names and grades/position(s): *
Please do not print this form.